Whitehaven Southwest Mental Health Center
Employment Application
General Information
First Name
*
Middle Initial
Last Name
*
Address
*
City
*
State
TN
AR
MS
KY
LA
GA
KS
AL
VA
IL
*
ZIP Code
*
Social Security Number
Home Telephone
Other Telephone
Email
Are you over 18 years of age?
Yes
No
*
What is your age?
Were you employed previously by us?
Yes
No
*
Are you a previous or current employed with a Behavioral Health Agency or any Agency that require a "State's" credentialing?
Yes
No
*
When? ( Please to and from dates)
Name
Position
Have you ever been convicted of a crime or entered in a diversion agreement?
Yes
No
*
Have you been dismissed, asked to resign, or left by mutual agreement from any position?
Yes
No
*
Please Explain
Position Desired
Position Applying For
*
Date Available
*
Minimum Wage Desired $
*
per
Hour
Year
*
Type
Full-time
Part-Time
Temporary
*
Preferred Shifts
Mornings
Afternoons
Evenings
Days
Saturdays
*
Hours you cannot work
Skill
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References
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Reference
Name
Organization/Position
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Telephone
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Relationship
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(Rounded to the nearest year)
Years Known
*
Education
High School
Name
*
Location
Diploma Received?
Yes
No
College/University
Name
Location
Major
Degree Received
Other Education
Name
Location
Training Received
Employment History
Please list most recent employer first
Employer
Company Name
Company Address
Company Phone
From (Month/Year)
To (Month/Year)
Your Position
Supervisor's Name
Supervisor's Position
Starting Salary
Ending Salary
Your Duties
Reason for Leaving
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Resume
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